Martin Brueck

A randomized comparison of transradial versus transfemoral approach for coronary angiography and angioplasty.

OBJECTIVES The aim of the study was to evaluate the safety, feasibility, and procedural variables by the transradial approach compared with the transfemoral access in a standard population of patients undergoing coronary catheterization. BACKGROUND Coronary catheterization is usually performed via the transfemoral approach. Transradial access may offer some advantages in comparison with transfemoral access especially under conditions of aggressive anticoagulation and antiplatelet treatment. METHODS Between July 2006 and January 2008, a total of 1,024 patients undergoing coronary catheterization were randomly assigned to the transradial or transfemoral approach. Patients with an abnormal Allens test, history of coronary artery bypass surgery, simultaneous right heart catheterization, chronic renal insufficiency, or known difficulties with the radial or femoral access were excluded. RESULTS Successful catheterization was achieved in 494 of 512 patients (96.5%) in the transradial and in 511 of 512 patients (99.8%) in the transfemoral group (p < 0.0001). Median procedural duration (37.0 min, interquartile range [IQR] 19.6 to 49.1 min vs. 40.2 min, IQR 24.3 to 50.8 min; p = 0.046) and median dose area product (38.2 Gycm(2), IQR 20.4 to 48.5 Gycm(2) vs. 41.9 Gycm(2), IQR 22.6 to 52.2 Gycm(2); p = 0.034) were significantly lower in the transfemoral group compared with the transradial access group. A median amount of contrast agent was similar among both groups. Vascular access site complications were higher in the transfemoral group (3.71%) than in the transradial group (0.58%; p = 0.0008) CONCLUSIONS The findings of the present study show that transradial coronary angiography and angioplasty are safe, feasible, and effective with similar results to those of the transfemoral approach. However, procedural duration and radiation exposure are higher using the transradial access. In contrast to the transfemoral route, the rate of major vascular complications was negligible using the transradial approach.

Sequential vs. kissing balloon angioplasty for stenting of bifurcation coronary lesions

Coronary angioplasty of bifurcation lesions remains a technical challenge and is believed to result in low procedural success associated with the risk of side‐branch occlusion. Furthermore, long‐term results are associated with a high rate of reintervention. The aim of the study was to evaluate the immediate and long‐term clinical and angiographic results of sequential vs. simultaneous balloon angioplasty (kissing balloon technique) for stenting of bifurcation coronary lesions. Between December 1999 and January 2001, 59 patients underwent coronary angioplasty because of symptomatic bifurcation lesions type III (i.e., side branch originates from within the target lesion of the main vessel, and both main and side branch are angiographically narrowed more than 50%). Twenty‐six patients were treated with simultaneous and 33 patients with sequential balloon angioplasty. Main‐vessel stent placement was mandatory; side‐branch stenting and platelet IIb/IIIa antagonists were allowed at the discretion of the operator. Kissing balloon technique offered no advantage in terms of procedural success or need for repeat target vessel revascularization due to restenosis at 6‐month follow‐up. Using sequential balloon angioplasty, permanent or transient side‐branch compromise rate (TIMI flow < 3) was significantly higher than after kissing balloon technique (33% vs. 0%, respectively; P = 0.003). Major clinical events in‐hospital or at 6‐month follow‐up, however, showed no significant differences. Kissing balloon angioplasty reduces the rate of transient side‐branch occlusion compared to sequential PTCA but does not improve immediate or long‐term outcome compared to sequential PTCA for stenting of bifurcation lesions. Cathet Cardiovasc Intervent 2002;55:461–466.

Does the number of simultaneously activated electrodes during phased RF multielectrode ablation of atrial fibrillation influence the incidence of silent cerebral microembolism

BACKGROUND Asymptomatic cerebral embolus (ACE) detected by diffusion-weighted magnetic resonance imaging (DW-MRI) following atrial fibrillation (AF) ablation has been reported at varying rates with different ablation techniques. OBJECTIVE To evaluate the incidence of ACE after phased radiofrequency ablation for AF with procedural modifications that potentially reduce the embolic load. METHODS One hundred twenty consecutive patients with AF underwent MRI before ablation, 24 hours after ablation, and at 4-6 weeks. In all patients, simultaneous activation of pulmonary vein ablation catheter electrode pairs 1 and 5 was forbidden. While in 60 group 1 patients, a maximum of 4 electrode pairs could be activated at a time, and in 60 group 2 patients, ablation was limited to a maximum of 2 pairs. All patients were on uninterrupted phenprocoumon, with an attempted activated clotting time of >300 seconds during ablation. RESULTS Both patient groups were comparable. A total of 28 DW-positive lesions were detected in 24 of 120 patients (20%). Seventeen group 1 patients (28.3%) were positive for new asymptomatic DW cerebral lesions compared with 7 group 2 patients (11.7%) (P = .039). During MRI follow-up, 3 patients (2.5%) were diagnosed with a small T2-positive asymptomatic glial scar. Procedure time was longer in group 2 patients than in group 1 patients (159 ± 39 vs 121 ± 15; P < .001). CONCLUSIONS Limiting the number of simultaneously activated electrode pairs to 2 significantly reduces the rate of ACE in patients treated with a multielectrode duty-cycled phased radiofrequency catheter system for AF. This reduction corresponds with a significant prolongation of the total procedure time.

Direct coronary stenting versus predilatation followed by stent placement

Direct stenting without antecedent dilatation may reduce procedural time, costs, and radiation exposure, and may result in less vessel injury. The purpose of this investigation was to compare immediate and long-term clinical and angiographic outcomes of direct stenting with stent placement after initial balloon dilation. Three hundred thirty-five symptomatic patients with single or multiple coronary lesions (diameter reduction 60% to 95%) of < or =30 mm length and with a vessel diameter of 2.5 to 4.0 mm were randomized either to direct stenting (group A, n = 171) or stenting after predilation (group B, n = 164). Patients with vessels with excessive calcification, severe proximal tortuosity, or occlusion were excluded. All patients were asked to return for routine repeat angiography at 6 months, irrespective of symptoms. Feasibility of direct stenting was 95% in group A, with 5% requiring crossover to predilation. Successful stent placement after predilation was performed in all 164 patients in group B. Direct stenting was associated with less procedural duration (group A 42.1 +/- 18.7 minutes vs group B 51.5 +/- 23.8 minutes, p = 0.004), radiation exposure time (group A 10.3 +/- 7.7 minutes vs group B 12.5 +/- 6.4 minutes, p = 0.002), amount of contrast dye used (group A 163 +/- 69 ml vs group B 197 +/- 84 ml, p <0.0001), and lower procedural costs (group A 845 +/- 167 vs group B 1,064 +/- 175, p <0.0001). Immediate angiographic results and in-hospital clinical outcomes (death, Q-wave myocardial infarction, repeat revascularization) were not significantly different between both strategies. However, at 6-month follow-up, direct stenting was associated with a lower angiographic restenosis (group A 20% vs group B 31%, p = 0.048) and target lesion revascularization rates (group A 18% vs group B 28%; p = 0.03). This study demonstrates the feasibility, safety, and outcomes of direct stenting in eligible coronary lesions. In appropriately selected cases, direct stenting has a lower rate of angiographic restenosis up to 6 months after the procedure, resulting in fewer coronary reinterventions compared with the conventional strategy of stenting with antecedent dilatation.

Myocardial ischemia due to an isolated coronary fistula

Dr. Martin C. Heidt Prof. Dr. Paul R. Vogt Klinik für Herz-, Kinderherzund Gefäßchirurgie Universitätsklinikum Gießen und Marburg Standort Gießen Rudolf-Buchheim-Straße 7 35392 Gießen, Germany Sirs: Coronary artery fistula is the most common form of congenital anomaly of the coronary arteries. Approximately half of all patients with coronary artery fistulas remain asymptomatic, the other half develop congestive heart failure, infective endocarditis, rupture of an aneurysmal fistula or myocardial ischemia induced by a coronary “steal” phenomenon.

Incidence of Coronary Artery Disease and Necessity of Revascularization in Symptomatic Patients Requiring Permanent Pacemaker Implantation

Background and Purpose:The cause of severe cardiac conduction disturbances or sinus node dysfunction is often unknown. The objective of this study was to assess the incidence of coronary artery disease (CAD) and the necessity of revascularization in patients with symptomatic bradycardia requiring permanent pacemaker implantation and to try to find a causal association between the need for a pacemaker and the presence of CAD.Patients and Methods:From January 2002 to December 2005, 507 pacemakers were implanted due to symptomatic bradycardia. In the presence of at least one atherosclerotic risk factor, patients were recommended to undergo coronary angiography. Each patient unterwent exercise or dobutamine echocardiography to detect myocardial ischemia.Results:212 of the 507 patients (42%) with permanent pacemaker implantation (141 men, mean age 70 ± 9 years) underwent coronary angiography within 2 months before or after pacemaker implantation. Twelve patients (6%) had a normal angiogram. No significant CAD was found in 37 patients (17%), and significant narrowing of the coronary arteries in 150 (71%). Conservative treatment was recommended in 128 patients (60%), 40 patients (19%) were treated with percutaneous coronary intervention, and 44 patients (21%) underwent coronary artery bypass grafting.Conclusion:The data indicate that patients with severe conduction disturbances or sinus node dysfunction requiring permanent pacemaker implantation are more likely to have CAD with subsequent myocardial revascularization in the presence of at least one atherosclerotic risk factor. A causal association between the need for pacemaker and CAD could not be established from the results.ZusammenfassungHintergrund und Ziel:Die Ursache bradykarder Rhythmusstörungen bleibt häufig ungeklärt. Ziel der Studie war die Evaluation der Inzidenz der koronaren Herzerkrankung und deren Behandlungsstrategie in einer Patientenklientel, die sich aufgrund bradykarder Herzrhythmusstörungen einer Schrittmacherimplantation unterzog.Patienten und Methodik:Im Zeitraum von Januar 2002 bis Dezember 2005 wurde bei 507 Patienten ein antibradykarder Schrittmacher implantiert. Bei Vorliegen mindestens eines kardiovaskulären Risikofaktors wurde den Patienten die Durchführung einer Koronarangiographie empfohlen, der eine dynamische oder pharmakologische Stress-Echokardiographie vorausging.Ergebnisse:Insgesamt 212 (141 Männer, mittleres Alter 70 ± 9 Jahre) der 507 Patienten (42%) wurden innerhalb 2 Monaten prä- oder postoperativ koronarangiographiert. Zwölf Patienten (6%) wiesen einen unauffälligen Koronarstatus auf, in 37 Fällen (17%) fanden sich Koronarstenosen < 50% und in 150 Fällen (71%) Koronarstenosen ≥ 50%. Ein konservatives Procedere wurde bei 128 Patienten (60%) empfohlen, bei 40 Patienten (19%) erfolgte eine katheterinterventionelle und bei 44 Patienten (21%) eine operative Myokardrevaskularisation.Schlussfolgerung:Patienten, die sich aufgrund bradykarder Rhythmusstörungen einer Schrittmacherimplantation unterziehen müssen, scheinen in Gegenwart mindestens eines kardiovaskulären Risikofaktors eine hohe Inzidenz der koronaren Herzerkrankung aufzuweisen, die häufig zu einer Revaskularisationsmaßnahme führt. Ein kausaler Zusammenhang zwischen der Notwendigkeit einer Schrittmacherimplantation und der koronaren Herzerkrankung kann jedoch aufgrund des Studiendesigns nicht nachgewiesen werden.

Rescue-Thrombektomie nach Stentimplantation in einem degenerierten aortokoronaren Venenbypass

ZusammenfassungHintergrund: Die kathetervermittelte Therapie degenerierter aortokoronarer Venenbypässe ist häufig mit einer periinterventionellen Embolisation von Thromben, Plaqueartikeln und atherosklerotischem Debris verbunden. Fallbeschreibung: Ein 66-jähriger männlicher Patient mit operativer Myokardrevaskularisation 1995 wurde aufgrund eines akuten koronaren Ischämiesyndroms in unsere Abteilung stationär eingewiesen. Unter einer antiischämischen Kombinationstherapie konnte eine klinische Stabilisierung erzielt werden. In einer elektiven Koronarangiographie stellten sich zwei kritische Stenosen im Venengraft zum Ramus interventricularis anterior (RIVA) als klinisch führende Läsionen heraus. Nach einer 24-stündigen Vorbehandlung mit einem Glykoprotein-IIb/IIIa-Inhibitor wurden im Bereich der distalen Stenose ein Stentgraft (Jostent™, Jomed) und im Bereich der proximalen Stenose ein Magic Wallstent™ (Boston Scientific) implantiert. Nach einer Hochdruckdilatation im Magic Wallstent™ verblieb keinerlei residuelle Stenose. Im weiteren Verlauf klagte der Patient über heftige Stenokardien, die mit ausgeprägten ST-Hebungen über den linkspräkordialen Ableitungen einhergingen. Angiographisch war der RIVA nach der koronaren Bypassanastomose okkludiert. Nach Einführen eines X-Sizer™-Absaugsystems (EndiCOR Medical, Inc.) in den Venengraft und das proximale Drittel der Vorderwandarterie konnte nach mehrfacher Aspiration eine komplette Reperfusion des RIVA wiederhergestellt werden. Die maximale CK-Aktivität betrug postinterventionell 127 U/l. In einer Kontrollkoronarangiographie nach 7 Tagen war der RIVA weiterhin perfundiert. Schlussfolgerung: Das X-Sizer™-Absaugsystem erscheint als eine erfolgversprechende Therapieoption zur perkutanen transluminalen Thrombektomie bei stattgehabter Makroembolisation mit No-Reflow-Phänomen bei Katheterinterventionen in degenerierten Venenbypässen.AbstractBackground: Distal showering of atherosclerotic debris or thrombus is a feared event during percutaneous angioplasty of degenerated vein grafts. Case Report: We report on a 66-year-old male patient with a history of coronary artery disease who was admitted into hospital with an acute coronary syndrome. He had had coronary artery bypass graft surgery in 1995. His chest pain resolved under treatment with aspirin, heparin, betablocker, and nitrate. A diagnostic angiogram demonstrated two critical stenoses of the left anterior descending graft. After a continuous infusion of tirofiban administered for 24 h prior to elective angioplasty, a JR 4SH 6 F guiding catheter (Cordis) was positioned. The lesions were crossed with a 0.014” Galeo F™ wire (Biotronik). A 4 mm × 16 mm stent graft (Jostent™, Jomed) was deployed in the distal stenosis and a 4,5 mm × 32 mm self-expandable stent (Magic Wallstent™, Boston Scientific) in the proximal stenosis. Thereafter, the patient suffered from chest pain, and the ECG showed ST elevation from V1 to V5. Angiography revealed total occlusion of the left anterior descending artery. An X-Sizer™ catheter (EndiCOR Medical, Inc.) was introduced and advanced through the vein graft with slow back-and-forth movements. After several aspirations, blood flow was significantly improved. A modest CK elevation (127 U/l) indicated a rather small loss of myocardial tissue. Conclusion: Percutaneous revascularization of narrowed aortocoronary saphenous vein grafts is associated with increased risk of distal embolization and “no flow”. The X-Sizer™ catheter system is compatible with commercially available guiding catheters, and capable of retrieving thrombotic debris after macroembolization from degenerated saphenous vein grafts including the native coronary artery.

Pneumoretroperitoneum und beidseitiger Pneumothorax nach endoskopischer Sphinkterotomie

HISTORY AND ADMISSION FINDINGS A 39-year-old obese woman underwent endoscopic retrograde cholangiopancreatography with elective endoscopic biliary sphincterotomy (papillotomy) for symptomatic retained stones in the common bile duct which were extracted completely after added lithotripsy. Three hours later the patient developed profound subcutaneous emphysema of the face, neck and chest wall and shortness of breath, but had no abdominal pain. Physical examination revealed bilaterally diminished breath sounds and a distended and hyper-resonant abdomen, but no evidence of peritonitis. The patient was afebrile and hemodynamically stable. INVESTIGATIONS An emergency contrast-enhanced computed tomography (CT) of the chest and abdomen was performed. It demonstrated a bilateral pneumothorax, pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum, in addition to extensive subcutaneous emphysema. There was no evidence of extraluminal leakage of contrast medium or intraperitoneal fluid on the CT. THERAPY AND CLINICAL COURSE Because of the increasing respiratory distress an intercostal drain was placed in the left pneumothorax and broad-spectrum antibiotics were administered. No drain was placed in the right lung. A follow-up CT after three days showed decreasing pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum as well as resolution of the bilateral pneumothorax. The patient made an uneventful recovery and was discharged home seven days after the intervention. CONCLUSION Pneumothorax after endoscopic biliary sphincterotomy is a rare but serious complication that should be kept in mind after postinterventional development of shortness of breath.

Inferior Vena Cava Approach to Permanent Pacemaker Implantation

A 89‐year‐old woman required permanent pacemaker implantation because of symptomatic bradyarrhythmia with multiple falls and repeated fractures. Because of the obstruction of the thoracic veins and infection of both groins, an alternative approach via directly punctured inferior vena cava was performed. At follow‐up, the patient remained well with an excellent symptomatic response to pacing. The method seems simple to perform and is an alternative when the usual pectoral implantation site is inaccessible.

Schweinehüterkrankheit als Differentialdiagnose des akuten Nierenversagens

Zusammenfassung.Hintergrund: Die Leptospirose ist eine weltweit verbreitete Anthropozoonose. Dabei ist Leptospira pomona als Erreger der Schweinehüterkrankheit (Maladie des jeunes porchers) mit benigner Verlaufsform einer Leptospirose bekannt. Fallbeschreibung: Ein 51-jähriger Landwirt wurde mit hohem Fieber, Ikterus und akutem Nierenversagen stationär aufgenommen. Laborchemisch zeigten sich erhöhte Retentions- und Entzündungsparameter, eine Thrombozytopenie, leicht erhöhte Transaminasen sowie eine Hyperlipasämie als Zeichen einer Pankreatitis. Eine Woche zuvor waren Muskelschmerzen, Fieber sowie Zephalgien aufgetreten. Unter der Verdachtsdiagnose einer Leptospirose wurde eine Penicillintherapie begonnen. Serologisch ließ sich innerhalb von 3 Wochen ein sechsfacher Titeranstieg gegen Leptospira pomona, den Erreger der Schweinehüterkrankheit, nachweisen. Unter intensivmedizinischer Behandlung konnte bei fallenden Retentionsparametern eine Nierenersatztherapie vermieden werden. Komplikationen durch die Thrombozytopenie oder Pankreatitis traten nicht auf. Ein Vorhofflimmern als Zeichen einer kardialen Beteiligung konvertierte, spontan in einen Sinusrhythmus. Der Patient wurde 3 Wochen nach der stationären Aufnahme entlassen. Schlussfolgerung: Die frühzeitige Diagnosestellung ist von entscheidender Bedeutung für die Prognose insbesondere der mit Komplikationen behafteten Verlaufsform einer Leptospirose. Auch die Schweinehüterkrankheit als meistens benigne Verlaufsform der Leptospirose kann in seltenen Fällen zu gravierenden Organmanifestationen mit Nierenversagen, Ikterus und Thrombozytopenie führen.Abstract.Background: Leptospirosis is a worldwide infectious disease affecting both animals and humans. Leptospira pomona is well known as a pathogen of a mild form of leptospirosis (maladie des jeune porchers). Case Report: A 51-year-old male farmer was referred to our hospital with high fever, hyperbilirubinemia and acute renal failure. Further laboratory tests revealed elevated inflammatory parameters, thrombocytopenia, signs of a mild hepatitis and involvement of pancreas. About 7 days before he had experienced muscle pain accompanied by headache and fever. Suspecting leptospirosis an intravenous therapy with penicillin was started. During the subsequent course of his illness a sixfold increase increase of antibody titer against leptospira pomona was documented within 3 weeks. Urine retention parameters decreased by intravenous fluid resuscitation in the intensive care unit, so that hemodialysis was not necessary. Platelets and bilirubin returned to normal. Atrial fibrillation as a sign of cardiac manifestation of leptospirosis changed spontaneously in a regular and permanent sinusrhythm. The patient was discharged home after 3 weeks in the hospital. Conclusion: Early diagnosis is most important for the prognosis of patients with severe form of leptospirosis. Leptospira pomona is a known pathogen of anicteric leptospirosis but in some cases is able to cause a severe form of leptospirosis with renal failure, jaundice and thrombocytopenia.